Wednesday, November 1st, Medicare Issues Revised LCD for PMDs

As a result of significant industry efforts to obtain clarifications and modifications to the Local Coverage Determination (LCD) for Power Mobility Devices (PMDs) that was released on September 20, 2006, the Medicare Durable Medical Equipment Program Safeguard Contractors (PSCs) have announced they have revised the LCD for PMDs. The implementation date of the revised LCD remains November 15, 2006. U.S. Rehab, along with other industry leaders, have been engaged in ongoing dialogue with the PSC Medical Directors on the importance of revising sections of the LCD and is pleased that Medicare has agreed to make these important revisions.

Changes/highlights below:

Single Power Option Chairs
Coverage criteria was changed to eliminate the reference to the number of actuators needed to operate the power positioning item. Coverage criteria for single power option chairs (either group 2 or group 3) is the following:

  1. The patient requires a drive control interface other than a hand or chin-operated standard proportional joystick (examples include but are not limited to head control, sip and puff, switch control); or
  2. The patient meets coverage criteria for a power tilt or a power recline seating system (see wheelchairs options and accessories policy for coverage criteria) and the system is being used on the wheelchairs; and
  3. The patient has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents medical necessity for the wheelchair and its specific features. The PT, OT, or physician may have no financial relationship with the supplier.

Multiple Power Option Chairs
Coverage criteria was changed to eliminate the reference to the number of actuators needed to operate the power positioning item. Coverage criteria for multiple power option chairs (either group 2 or group 3) is the following:

  1. The patient meets coverage criteria for a power tilt and recline seating system (reference the Wheelchair Options and Accessories policy within the LCD) and the system is being used on the wheelchair; or
  2. The patient uses a ventilator which is mounted on the wheelchair; and
  3. The patient has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents medical necessity for the wheelchair and its specific features. The PT, OT, or physician may have no financial relationship with the supplier.

Group 3 Power Wheelchairs
Coverage criteria for Group 3 power wheelchairs was changed to eliminate the “unable to independently stand and pivot to transfer” requirement. Coverage criteria for Group 3 power wheelchairs is the following:

  1. All of the basic coverage criteria for a power wheelchair are met; and
  2. The patient’s mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity; and
  3. The patient has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents medical necessity for the wheelchair and its specific features. The PT, OT, or physician may have no financial relationship with the supplier.

Advance Determination of Medicare Coverage (ADMC)

  1. Medicare has expanded the power wheelchairs that are eligible for Advance Determination of Medicare Coverage. Single Power Option or Multiple Power Option wheelchairs in Group 2, 3, 4, and 5 are now eligible for ADMC regardless of whether a power seating system will be provided at the time of initial issue. Per Medicare, “This will permit advance determination for a patient with a progressive neurological disease, such as amyotrophic lateral sclerosis (ALS) or multiple sclerosis (MS), who does not yet need a power seating system but the documentation from the face to face exam supports the need for such a system in the future.”
  2. ADMC continues to be available for Groups 2-5 power wheelchairs that will be provided with an alternative drive control interface at the time of initial issue.

Note: The specialty evaluation by a RESNA certified ATP is still required for patients receiving a group 2 single power option or multiple power option or any group 3 or 4 power wheelchair as of April 1, 2008.

The complete revised LCD can be found at:
Complete Revised LCD

If you have any questions on this information, please contact U.S. Rehab at 800-987-7342.